Furness General Hospital
Good

Reports

Inspection carried out on 11-14 and 26 October 2016

During an inspection to make sure that the improvements required had been made

We carried out a follow up inspection between 11 and 14 October 2016 to confirm whether University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) had made improvements to its services since our previous comprehensive inspection, in July 2015. We also undertook an unannounced inspection on 26 October 2016.

To get to the heart of patients’ experiences of care and treatment, we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

When we last inspected this hospital, in July 2015, we rated services overall as 'requires improvement'. We rated safe, effective, responsive, and well-led as 'requires improvement'. We rated caring as 'good'.

There were seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, supporting staff, safety and suitability of premises, safe care and treatment, and assessing and monitoring the quality of service provision.

The trust sent us an action plan telling us how it would ensure that it had made the improvements required in relation to these breaches of regulation. At this inspection we checked whether these actions had been completed.

We found that the trust had made the required improvements and rated Furness General Hospital as 'good' overall, with caring rated as 'outstanding' and safe rated as 'requires improvement'.

Our key findings were as follows:

There had been significant improvements across most services at this hospital since our last inspection in July 2015.

In medical and end of life care services, there were a number of outstanding examples of compassionate care and emotional support shown by all levels and disciplines of staff, who did not hesitate to go the extra mile to make a difference for patients and their loved ones.

Leadership of the hospital was good, managers were available, visible, and approachable; staff morale had improved significantly and they felt supported. Staff spoke positively about the service they provided for patients.

There had been significant investment in leadership within end of lfe services.

Staff knew the process for reporting and investigating incidents using the trust's reporting system. They received feedback from reported incidents and felt supported by managers when considering lessons learned.

The hospital had in place infection prevention and control policies which were accessible, understood and used by staff. Patients received care in a clean, hygienic and suitably maintained environment.

The trust reported no incidences of MRSA between September 2015 and May 2016. Eight cases of clostridium difficile were reported in the same period.

We saw that patients were assessed using a nutritional screening tool, had access to a range of dietary options and were supported to eat and drink.

Nursing and medical staffing numbers had improved since the last inspection. However, there were still several of nursing and medical staffing vacancies throughout the hospital, especially in medical care services and the emergency department. The trust had robust systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care.

The hospital had improved compliance against mandatory training and appraisal targets in most services. Local support and supervision of junior staff had improved, and many areas had developed their own unit-specific competencies for training and development purposes.

There had been an improvement in record-keeping standards throughout the hospital, however, we identified some ongoing areas for improvement around legibility and trigger-levels for early warning of deterioration, particularly in in medical care services and the emergency department.

The trust’s referral to treatment time (RTT) for admitted pathways for surgery services had improved since the last inspection. Information for September 2016 showed an improvement in the trust’s performance, with 75% of this group of patients treated within 18 weeks, against the England average of 75%.

Access and flow, particularly in the emergency department and medical care services, remained a challenge. The emergency department's performance had been deteriorating over the preceding 12 months. The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the A&E. The trust breached the standard between October 2015 and September 2016. Lack of beds in the hospital resulted in patients waiting longer in the emergency department. Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.

We saw several areas of outstanding practice including:

The medicine division delivered outstanding Referral to Treatment (RTT) outcomes across all specialisms despite pressures on the service overall.

The Listening into Action programme had delivered some clear, effective and significant quality improvements for the organisation and for patients across the hospital.

There were many examples of public engagement in the development and delivery of maternity services, such as co-designing the new maternity unit, interviews for recruitment of new staff, including midwives and matrons, and the development of guidelines and strategies.

The service was one of three trusts which were successful in securing funding to pilot a maternity experience communication-improvement project. This was a patient-basedtraining tool for multi-professional groups in maternity services. The project had the potential to be adopted nationally if learning outcomes and measurable improvements could be made for women who were using maternity services.

The bereavement team, Chaplaincy and specialist palliative care team worked together to promote compassionate care at the end of life. A particular innovation relating to this had been the development of death cafés. A death café provided an opportunity for people to talk more openly about death and dying. The trust had held death cafés for the public as part of 'dying matters week' and also had used them to support staff to talk more openly about death and to promote better communication with patients and relatives at the end of life.

There were a number of innovations relating to compassionate care for patients at the end of life. This included the use of canvas property bags with a dragonfly symbol so staff knew that thosecollecting them had been recently bereaved. In addition, bereavement staff sent out forget-me-not seeds to family members following the death of a loved one. Families were also able to get casts of patient’s hands. This was a service provided by an external organisation with funding provided by the trust.

The trust had adopted the dragonfly as the dignity in death symbol. This was used as a sign to alert non-clinical staff to the fact that a patient was at the end of life or had died. A card with the symbol could be clipped to the door or curtain where the patient was being cared for. By alerting all staff this meant that patients and family members would not have to face unnecessary interruptions and non-clinical staff knew to speak with clinical staff before entering the room. An information card had been produced for non-clinical staff explaining the difference between the dragonfly symbol (dignity in death) and the butterfly (dementia care).

A remembrance service was held by the Chaplaincy every three months for those bereaved. We were also told that ‘shadow’ funeral services had been delivered within the trust when patients had been too unwell to attend funerals of loved ones.

Relatives were sent a condolence letter by the bereavement service a few weeks after the death of a loved oneand support was offered at this time.

The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

In urgent and emergency care services:

Monitor performance information to ensure 95% of patients are admitted, transferred or discharged within four hours of arrival in the emergency department;

Ensure patients do not wait longer than the standard for assessment and treatment in the emergency department.

Action the hospital SHOULD take to improve

In urgent and emergency care services:

Ensure observations are recorded appropriately to allow the assessment and early recognition of the deteriorating patient;

Ensure nursing documentation is completed in accordance with the trust policy;

Continue to ensure that staff complete mandatory training in accordance with trust policy;

Continue to ensure equipment checks are completed consistently in accordance with trust policy;

Ensure the regular update of patient group directions in accordance with trust policy.

In medical care:

Ensure all nursing and medical clinical documentation is completed legibly, in full and in accordance with recognised professional standards;

Ensure multi-factorial falls risk assessments are completed in all cases where risk is indicated and that this is evidenced in the electronic patient record or in the medical notes;

Ensure robust divisional oversight of the respiratory unit at Furness General Hospital (FGH) due to shortfalls in substantive senior medical presence onsite, vulnerability of senior medical staffing and reliance upon senior locum contracts;

Ensure that, where medicines are stored in fridges, temperature ranges are recorded in accordance with policy to ensure that the safety and efficacy of the medicine is not compromised;

Ensure all staff complete all elements of their mandatory training requirements and ensure accurate compliance figures are maintained;

Ensure all staff benefit from the appraisal process and that appraisals are completed on an annual basis in accordance with local policy;

Ensure action plans put in place to address shortfalls in local and national patient outcome audits findings are monitored and reviewed in a reasonable time-frame to ensure compliance is measured;

Ensure there is a review of patient comments and Patient Led Assessment of the Care Environment (PLACE) findings regarding food quality, and consider measures which may be implemented to improve nutritional care;

Ensure staff awareness and knowledge of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) is underpinned by consideration of procedural competence in making such application, to avoid potential legislative breaches;

Ensure all patients are aware of alternative treatment options (including risks and benefits) in addition to recommended treatment options;

Ensure the number of patient bed moves after 10pm is kept to a minimum to avoid patient and family anxiety and distress;

Ensure the remit of the nurse-led ambulatory care unit is fully understood by all key personnel to ensure its safety and efficiency in delivering patient care;

Ensure the effectiveness of the new governance framework is measured and adaptationsare made accordingly;

Ensure the effectiveness of current staff engagement themes and consider other formats which may support divisional strategy and staff harmony;

Ensure reasonable measures are put in place to support staff wellbeing and ensure all staff know what support is available to them.

In surgery:

Continue to improve Referral to Treatment Times (RTT) for patients and continue to implement trustwide initiatives to improve response;

Prioritise hip fractures (within 48 hours);

Ensure all transfers between locations are performed in line with best practice guidance and policy. Where practice deviates from the guidance, a clear risk assessment should be in place;

Continue to engage staff and encourage team-working to develop and improve the culture within the wards and theatre department;

Continue with staff recruitment and retention;

Improve the completion of NEWS;

Improve environmental cleanliness;

Improve the monitoring of fridge temperature and take action if temperatures exceed the expected range;

In critical care:

There was no provision for dedicated critical care pharmacy cover at the FGH site, despite recommendation of such by GPICS (2015). The critical care unit should take action to create plans that adhere to this guidance;

The unit should take action to improve physiotherapy staffing and be clear about how it supports rehabilitation for patients in line with GPICS (2015);

Patients discharged from critical care should receive a ward follow up visit by critical care nurses within 36 hours of discharge, planned as part of the appointment of a supernumerary coordinator and in accordance withthe GPICS (2015) standard;

The unit should continue to monitor discharges out of hours, and develop actions to improve (reduce) the number of FGH critical care discharges out of hours.

In maternity and gynaecology:

Ensure that outcome measures are developed to monitor the effectiveness of the strategic partnership with Central Manchester and Lancashire NHS Trusts;

Continue to monitor the cultural assessment survey for obstetrics and gynaecology and improve values around organisational culture.

In services for children and young people:

The hospital should ensure there is a review of all children and young people’s mortality and morbidity;

The hospital should ensure that documentation refers to Gillick competency and that staff are properly trained and confident to assess Gillick competency;

The hospital should continue to ensure that communication takes place with partner agencies about the placement of CAMHS patients.

In outpatients and diagnostic imaging:

The trust should continue to build relationships and develop closer team working for medical staff in radiology and breast services across all locations to develop a one trust culture;

The trust should continue to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to meet the needs of the patients. This is particularly in relation to radiology, dermatology and allied health professionals;

The trust should continue work to ensure that all premises used are suitable for the purpose for which they are being used, are properly used, are properly maintained and are appropriately located for the purpose for which they are being used. This is particularly in relation to services provided from medical unit one;

The trust should ensure that it meets referral to treatment targets in outpatient clinics and that it addresses backlogs in follow up appointment waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During an inspection to make sure that the improvements required had been made

Furness General Hospital is one of three locations providing care as part of University Hospitals of Morecambe Bay NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, an oncology unit, a neonatal unit, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services.

University Hospitals of Morecambe Bay NHS Foundation Trust provides services for around 360,000 people across North Lancashire and South Cumbria with over 700 beds. In total, Furness General Hospital has 239 beds.

We inspected University Hospitals of Morecambe Bay NHS Foundation Trust as part of our comprehensive inspection programme in February 2014. Following our inspection in February 2014 we rated the Furness General Hospital as ‘Requires Improvement’ overall. We judged the hospital as ‘Inadequate’ for safe, ‘Requires Improvement’ for responsive and well led and ‘good’ for effective and caring. CQC was specifically concerned about nursing staffing shortfalls, particularly in the critical care and high dependency units as well as medical wards in this hospital. Patient records, including risk assessments and care planning documentation were not always accurately and comprehensively completed. We also found the trust’s governance and management systems were inconsistently applied across services and the quality of performance management information required improvement.

We carried out this inspection to see whether the hospital had made improvements since our last inspection. We carried out an announced inspection of Furness General Hospital between 14 and 17 July 2015.

Overall we rated Furness General Hospital as ‘Requires Improvement’. We have judged the service as ‘good’ for caring, and ‘requires improvement' for safe, effective, responsive and well-led care.

Our key findings were as follows:

Cleanliness and infection control

The trust had infection prevention and control policies in place which were accessible to staff.

We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.

‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.

Overall, patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.

In surgical services,. between April 2014 and February 2015, there had been seven avoidable cases in the surgical and critical care division at Furness General Hospital. On one ward there had been three cases in two months. This had resulted in additional information regarding control of this infection and hand hygiene being provided to all staff during the safety huddles.

According to the submitted and verified intensive care national audit and research centre data (ICNARC), the unit performed as well and sometimes better than similar units for unit acquired methicillin-resistant staphylococcus aureus (MRSA) and clostridium difficile infection rates.

Nurse staffing

Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.

The trust had actively recruited nursing staff from overseas to try to improve staffing levels. However, vacancy rates remained high and shortfalls were covered by bank and agency staff. Senior staff said that they tried to use the same bank and agency staff to ensure that they had the required skills to work on the ward. Agency staff were given an induction before commencing work on the wards.

Nurses recruited from overseas were supernumerary while they awaited registration with the Nursing and Midwifery Council. However, in surgical services there was a lack of clarity about their role and responsibilities.

Staffing establishments had improved since the last inspection however on some wards nurse staffing remained a challenge, particularly within medicine. A review of staffing within medicine showed that the skill mix did not always fall in line with the trust’s ‘red rules’ initiative. The principles of this initiative included: one registered nurse should deliver care to no more than eight patients and the minimum skills mix on a ward should be 60% registered nurses to 40% health care assistants.

Medical staffing

Medical treatment was delivered by skilled and committed medical staff.

The trust had identified areas where medical staff shortages presented risk to patient care and treatment and were working hard to recruit and retain consultants.

Recruitment of consultants was a challenge particularly in Emergency and urgent care services, and respiratory and gastroenterology.

In surgical services, 21% of medical staff posts were vacant in May 2015. This had resulted in increased locum medical cover with the highest use being in the urology speciality where 55% of medical cover was by agency staff in May 2015.

There were ongoing vacancies within the radiology service. Managers said they were actively recruiting and had introduced the use of extended roles for advanced practitioners to help manage the case load. The service leads felt there had been some improvements in staffing but the recruitment of experienced radiology staff remained a challenge.

There was a sufficient number of medical staff to support outpatient services. The majority of clinics were covered by specialist consultants and their medical teams.

Mortality rates

The trust was highlighted as a ‘risk’ for the in-hospital mortality indicator - Cerebrovascular conditions in the CQC Intelligent monitoring report May 2015.

Mortality and morbidity meetings were held weekly or monthly and were attended by representatives from all teams within the relevant divisions. As part of these meetings, attendees reviewed the notes for patients who had died in the hospital within the previous week. Any learning identified was shared and applied.

Nutrition and hydration

Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and by the speech and language therapy team.

The patient records we reviewed included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool (MUST).

Where patients were identified as being at risk, there were fluid and food charts in place. However, the recording of fluid balance charts was inconsistent.

Parents told us there was a good selection of food on the menu for children and young people. Children were also offered snacks and food was available as it was required.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Ensure that all premises used by the service provider are clean, secure, suitable for the purpose for which they are being used, properly used, properly maintained and appropriately located for the purpose for which they are being used. This is particularly in relation to services provided from critical care and outpatients.

Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to meet the needs of the patients. This is particularly in relation to medical care, children and young people's services, and radiology, dermatology and allied health professionals.

Ensure that staff receive appropriate support, training, supervision and appraisal to enable them to carry out the duties they are employed to perform, particularly in Accident and Emergency, medical and surgical services and Children and Young People's services.

Ensure that staff understand and act in accordance with the requirements of the Mental Capacity Act 2005 and associated codes of practice.

Ensure referral to treatment times in surgical specialities improve.

Ensure that staff follow policies and procedures around managing medicines, including intravenous fluids particularly in children and young people's and critical care services.

Ensure that risk registers clearly identify all risks within the division, the actions taken to mitigate those risks and demonstrate timely review, particularly in medical care.

Maintain securely an accurate, complete and contemporaneous record in respect of each service user, including medical and nursing, and food and fluid charts, particularly in medical and surgical services.

Improve staff engagement, knowledge and awareness of the strategy for the service.

In medical care services:

Ensure there are clear plans in place to reduce the number of falls occurring within the service.

Improve the management of people with a stroke in line with national guidance.

Consider improving arrangements for clinical supervision to ensure they are appropriate and support staff to effectively carry out their responsibilities, offer relevant development opportunities and enable staff to deliver care safely and to an appropriate standard.

Take action to reduce the number of patients staying on medical wards that are not best suited to their needs and to reduce the number of moves between wards.

In surgical services:

Ensure all staff understand the process for raising safeguarding referrals in the absence of the safeguarding lead.

Reduce and improve re-admission rates.

Ensure all procedures are performed in line with best practice guidance. Where practice deviates from the guidance, a clear risk assessment should be in place.

In critical care services:

Ensure that there is timely access to medical care for patients out of hours and that any delays do not result in patient harm.

Consider how it is going to improve performance in reducing the number of delayed and out of hours discharges of patients from critical care.

Ensure that any delayed discharges from critical care do not result in a breach of the government’s single sex standard.

Ensure that all entries in patient records are appropriately signed and dated.

Consider the provision of a supernumerary clinical co-ordinator on duty 24/7.

Consider how it intends to respond to the latest Health Building Notes guidance for critical care units in planning its vision and strategy for the service.

In maternity and gynaecology services:

Ensure that the actions of the Kirkup recommendations are implemented within timescales and embedded across the trust.

Ensure there are clear lines of responsibility and accountability at ward manager and matron level within maternity so that staff feel supported and barriers to communication and change are removed.

Implement the recommendations of and monitor compliance with, the PHSO Report 'Midwifery supervision and regulation: recommendations for change' (2013) with regard to Trust/Midwifery Supervisory investigations, so that parent(s) receive a joint set of recommendations and a single timeframe resulting from the investigation.

Professor Sir Mike Richards

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During a routine inspection

We carried out a follow up inspection between 11 and 14 October 2016 to confirm whether University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB) had made improvements to its services since our previous comprehensive inspection, in July 2015. We also undertook an unannounced inspection on 26 October 2016.

To get to the heart of patients’ experiences of care and treatment, we always ask the same five questions of all services: are they safe, effective, caring, responsive to people’s needs, and well-led? Where we have a legal duty to do so, we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

When we last inspected this hospital, in July 2015, we rated services overall as 'requires improvement'. We rated safe, effective, responsive, and well-led as 'requires improvement'. We rated caring as 'good'.

There were seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations. These were in relation to staffing, supporting staff, safety and suitability of premises, safe care and treatment, and assessing and monitoring the quality of service provision.

The trust sent us an action plan telling us how it would ensure that it had made the improvements required in relation to these breaches of regulation. At this inspection we checked whether these actions had been completed.

We found that the trust had made the required improvements and rated Furness General Hospital as 'good' overall, with caring rated as 'outstanding' and safe rated as 'requires improvement'.

Our key findings were as follows:

There had been significant improvements across most services at this hospital since our last inspection in July 2015.

In medical and end of life care services, there were a number of outstanding examples of compassionate care and emotional support shown by all levels and disciplines of staff, who did not hesitate to go the extra mile to make a difference for patients and their loved ones.

Leadership of the hospital was good, managers were available, visible, and approachable; staff morale had improved significantly and they felt supported. Staff spoke positively about the service they provided for patients.

There had been significant investment in leadership within end of lfe services.

Staff knew the process for reporting and investigating incidents using the trust's reporting system. They received feedback from reported incidents and felt supported by managers when considering lessons learned.

The hospital had in place infection prevention and control policies which were accessible, understood and used by staff. Patients received care in a clean, hygienic and suitably maintained environment.

The trust reported no incidences of MRSA between September 2015 and May 2016. Eight cases of clostridium difficile were reported in the same period.

We saw that patients were assessed using a nutritional screening tool, had access to a range of dietary options and were supported to eat and drink.

Nursing and medical staffing numbers had improved since the last inspection. However, there were still several of nursing and medical staffing vacancies throughout the hospital, especially in medical care services and the emergency department. The trust had robust systems in place to manage staffing shortfall as well as escalation processes to maintain safe patient care.

The hospital had improved compliance against mandatory training and appraisal targets in most services. Local support and supervision of junior staff had improved, and many areas had developed their own unit-specific competencies for training and development purposes.

There had been an improvement in record-keeping standards throughout the hospital, however, we identified some ongoing areas for improvement around legibility and trigger-levels for early warning of deterioration, particularly in in medical care services and the emergency department.

The trust’s referral to treatment time (RTT) for admitted pathways for surgery services had improved since the last inspection. Information for September 2016 showed an improvement in the trust’s performance, with 75% of this group of patients treated within 18 weeks, against the England average of 75%.

Access and flow, particularly in the emergency department and medical care services, remained a challenge. The emergency department's performance had been deteriorating over the preceding 12 months. The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the A&E. The trust breached the standard between October 2015 and September 2016. Lack of beds in the hospital resulted in patients waiting longer in the emergency department. Delays in obtaining suitable community care placements were causing access and flow difficulties, particularly in medical care services.

We saw several areas of outstanding practice including:

The medicine division delivered outstanding Referral to Treatment (RTT) outcomes across all specialisms despite pressures on the service overall.

The Listening into Action programme had delivered some clear, effective and significant quality improvements for the organisation and for patients across the hospital.

There were many examples of public engagement in the development and delivery of maternity services, such as co-designing the new maternity unit, interviews for recruitment of new staff, including midwives and matrons, and the development of guidelines and strategies.

The service was one of three trusts which were successful in securing funding to pilot a maternity experience communication-improvement project. This was a patient-basedtraining tool for multi-professional groups in maternity services. The project had the potential to be adopted nationally if learning outcomes and measurable improvements could be made for women who were using maternity services.

The bereavement team, Chaplaincy and specialist palliative care team worked together to promote compassionate care at the end of life. A particular innovation relating to this had been the development of death cafés. A death café provided an opportunity for people to talk more openly about death and dying. The trust had held death cafés for the public as part of 'dying matters week' and also had used them to support staff to talk more openly about death and to promote better communication with patients and relatives at the end of life.

There were a number of innovations relating to compassionate care for patients at the end of life. This included the use of canvas property bags with a dragonfly symbol so staff knew that thosecollecting them had been recently bereaved. In addition, bereavement staff sent out forget-me-not seeds to family members following the death of a loved one. Families were also able to get casts of patient’s hands. This was a service provided by an external organisation with funding provided by the trust.

The trust had adopted the dragonfly as the dignity in death symbol. This was used as a sign to alert non-clinical staff to the fact that a patient was at the end of life or had died. A card with the symbol could be clipped to the door or curtain where the patient was being cared for. By alerting all staff this meant that patients and family members would not have to face unnecessary interruptions and non-clinical staff knew to speak with clinical staff before entering the room. An information card had been produced for non-clinical staff explaining the difference between the dragonfly symbol (dignity in death) and the butterfly (dementia care).

A remembrance service was held by the Chaplaincy every three months for those bereaved. We were also told that ‘shadow’ funeral services had been delivered within the trust when patients had been too unwell to attend funerals of loved ones.

Relatives were sent a condolence letter by the bereavement service a few weeks after the death of a loved oneand support was offered at this time.

The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

In urgent and emergency care services:

Monitor performance information to ensure 95% of patients are admitted, transferred or discharged within four hours of arrival in the emergency department;

Ensure patients do not wait longer than the standard for assessment and treatment in the emergency department.

Action the hospital SHOULD take to improve

In urgent and emergency care services:

Ensure observations are recorded appropriately to allow the assessment and early recognition of the deteriorating patient;

Ensure nursing documentation is completed in accordance with the trust policy;

Continue to ensure that staff complete mandatory training in accordance with trust policy;

Continue to ensure equipment checks are completed consistently in accordance with trust policy;

Ensure the regular update of patient group directions in accordance with trust policy.

In medical care:

Ensure all nursing and medical clinical documentation is completed legibly, in full and in accordance with recognised professional standards;

Ensure multi-factorial falls risk assessments are completed in all cases where risk is indicated and that this is evidenced in the electronic patient record or in the medical notes;

Ensure robust divisional oversight of the respiratory unit at Furness General Hospital (FGH) due to shortfalls in substantive senior medical presence onsite, vulnerability of senior medical staffing and reliance upon senior locum contracts;

Ensure that, where medicines are stored in fridges, temperature ranges are recorded in accordance with policy to ensure that the safety and efficacy of the medicine is not compromised;

Ensure all staff complete all elements of their mandatory training requirements and ensure accurate compliance figures are maintained;

Ensure all staff benefit from the appraisal process and that appraisals are completed on an annual basis in accordance with local policy;

Ensure action plans put in place to address shortfalls in local and national patient outcome audits findings are monitored and reviewed in a reasonable time-frame to ensure compliance is measured;

Ensure there is a review of patient comments and Patient Led Assessment of the Care Environment (PLACE) findings regarding food quality, and consider measures which may be implemented to improve nutritional care;

Ensure staff awareness and knowledge of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) is underpinned by consideration of procedural competence in making such application, to avoid potential legislative breaches;

Ensure all patients are aware of alternative treatment options (including risks and benefits) in addition to recommended treatment options;

Ensure the number of patient bed moves after 10pm is kept to a minimum to avoid patient and family anxiety and distress;

Ensure the remit of the nurse-led ambulatory care unit is fully understood by all key personnel to ensure its safety and efficiency in delivering patient care;

Ensure the effectiveness of the new governance framework is measured and adaptationsare made accordingly;

Ensure the effectiveness of current staff engagement themes and consider other formats which may support divisional strategy and staff harmony;

Ensure reasonable measures are put in place to support staff wellbeing and ensure all staff know what support is available to them.

In surgery:

Continue to improve Referral to Treatment Times (RTT) for patients and continue to implement trustwide initiatives to improve response;

Prioritise hip fractures (within 48 hours);

Ensure all transfers between locations are performed in line with best practice guidance and policy. Where practice deviates from the guidance, a clear risk assessment should be in place;

Continue to engage staff and encourage team-working to develop and improve the culture within the wards and theatre department;

Continue with staff recruitment and retention;

Improve the completion of NEWS;

Improve environmental cleanliness;

Improve the monitoring of fridge temperature and take action if temperatures exceed the expected range;

In critical care:

There was no provision for dedicated critical care pharmacy cover at the FGH site, despite recommendation of such by GPICS (2015). The critical care unit should take action to create plans that adhere to this guidance;

The unit should take action to improve physiotherapy staffing and be clear about how it supports rehabilitation for patients in line with GPICS (2015);

Patients discharged from critical care should receive a ward follow up visit by critical care nurses within 36 hours of discharge, planned as part of the appointment of a supernumerary coordinator and in accordance withthe GPICS (2015) standard;

The unit should continue to monitor discharges out of hours, and develop actions to improve (reduce) the number of FGH critical care discharges out of hours.

In maternity and gynaecology:

Ensure that outcome measures are developed to monitor the effectiveness of the strategic partnership with Central Manchester and Lancashire NHS Trusts;

Continue to monitor the cultural assessment survey for obstetrics and gynaecology and improve values around organisational culture.

In services for children and young people:

The hospital should ensure there is a review of all children and young people’s mortality and morbidity;

The hospital should ensure that documentation refers to Gillick competency and that staff are properly trained and confident to assess Gillick competency;

The hospital should continue to ensure that communication takes place with partner agencies about the placement of CAMHS patients.

In outpatients and diagnostic imaging:

The trust should continue to build relationships and develop closer team working for medical staff in radiology and breast services across all locations to develop a one trust culture;

The trust should continue to ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed in order to meet the needs of the patients. This is particularly in relation to radiology, dermatology and allied health professionals;

The trust should continue work to ensure that all premises used are suitable for the purpose for which they are being used, are properly used, are properly maintained and are appropriately located for the purpose for which they are being used. This is particularly in relation to services provided from medical unit one;

The trust should ensure that it meets referral to treatment targets in outpatient clinics and that it addresses backlogs in follow up appointment waiting times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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During an inspection to make sure that the improvements required had been made

We visited the Furness General Hospital (FGH) to check that improvements had been made to cleanliness and hygiene following an inspection that found the hospital non compliant with Outcome 8, cleanliness and infection control.

We spoke with people who used the service (patients) and asked if they were satisfied with the care they received, they told us:

We found that the University Hospitals of Morecambe Bay Trust had made the required improvements to achieve compliance with cleanliness and infection control, specifically within its accident and emergency department.

We had also received information of concern from a member of the public about a specific ward at the hospital. On inspection of the ward we found that patients were being looked after to an appropriate standard. We did identify areas that required improvement around palliative care, however the Trust was already aware of some of the issues and were working towards improving practices.

During a routine inspection

This inspection focused purely on the maternity service at Furness General Hospital and The Royal Lancaster Infirmary. We have written a report for each separate location and therefore to get an overview of the maternity service provided by The University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) both reports should be read in conjunction with each other.

All the women we spoke with who were using the maternity services at Furness General Hospital expressed satisfaction with the care and support they had received. We were told that midwives were “Understanding”. One person told us that staff had “Gone out of their way to explain and talk me through it”. People told us, and we observed, that their privacy was respected. Curtains were drawn around beds for privacy and staff asked permission to enter.

Medical and midwifery staff we spoke with were aware of the processes to raise and escalate any concerns or incidents. They expressed confidence in using this system. We found that learning from ‘near misses’ was being shared. A regular staff newsletter and information posters in clinical areas on the lessons learned from the analysis of incidents helped make sure all staff were kept informed.

We found that staffing and skill mix on the different wards was being continuously reviewed. We saw that staff had moved around the service to help make sure service provision and quality of care was maintained. Women were at times diverted to other Maternity units to enable provision of safe care.

Alterations had been made to the location and facilities of the Special Care Baby Unit (SCBU) at FGH. We found that staff recruitment remained a problem in the long term for this unit. In the short term an effective service was being provided by staff working additional hours.

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During an inspection to make sure that the improvements required had been made

We visited the A&E department at Furness General Hospital as part of a review following an investigation into the emergency care pathway undertaken in 2012 under section 48 (1) (2) (a) of the Health and Social Care Act 2008 which enabled the CQC to look at the provision and commissioning of health care more widely beyond the 16 outcomes within the essential outcomes of quality and safety.

During the review we found that patients were not cared for in a clean, hygienic environment within the A&E department. Health and social care providers are required to follow the guidance laid out in the Department of Health's publication: The Code of Practice for health and adult social care on the prevention and control of infections and related guidance. This guidance forms part of outcome 8: cleanliness and infection control underpinned by Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

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During an inspection to make sure that the improvements required had been made

This unannounced inspection along with a second one at the Royal Lancaster Infirmary (RLI) on the 13 August 2012 focussed on the accident and emergency department including the medical assessment unit (MAU).

During our visit to Furness General Hospital (FGH) we spoke with six people using the service and three of those had come into hospital via the A&E department. The people we spoke with were complimentary about the care they had received from staff in A&E.

Another person told us “They (A&E staff) have been wonderful” and “the nurses have infinite patience” and “the food is very good.”

Another said “I can’t fault anything.”

As part of our inspection we spoke with stakeholders such as the local council’s Overview & Scrutiny Committee who have a duty to look more closely into public services outside their own organisation, which includes local NHS hospitals. They said they had not received any concerns from the public about the accident and emergency departments in recent months. They told us they had regular meetings with senior staff at University Hospitals of Morecambe Bay Trust which kept them up to date with any changes in service provision at the trust. They were fully aware of the issues in the past that had led us to issue a warning notice.

We also spoke with the Local Involvement Networks (LINks) who had also not recently received any issues or concerns from the public about the emergency departments.

We inspected FGH to check compliance with a warning notice served in February 2012 and to follow up compliance actions from the last inspection report. We had issued warning notices and compliance actions across FGH and RLI for the provision of emergency care.

A separate report has been written for RLI. Although the previous reports highlighted some different issues for each site there were common themes identified across both so it is beneficial to read this report in conjunction with the one for RLI.

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During an inspection to make sure that the improvements required had been made

This report concerns the Furness General Hospital maternity unit.

Women we spoke with were all pleased with the level of care they had received.

One woman told us "I have no problems. I am happy with the service. I have been given lots of explanations and information. I have had no problems or concerns about lack of privacy or dignity."

As part of our inspection we spoke with local stakeholders such as the local councils Overview & Scrutiny Committee who have a duty to look more closely into public services outside their own organisation which includes local NHS hospitals. They said they had not received any concerns from the public about Furness General Hospital or the Royal Lancaster Infirmary maternity units in recent months. They told us they had regular meetings with senior staff at University Hospitals of Morecambe Bay Trust which kept them up to date with any changes in service provision at the trust.

We also spoke with the Local Involvement Networks (LINks) who had not received any issues or concerns from the public about the provision of maternity services at University Hospitals of Morecambe Bay.

We inspected Furness General Hospital (FGH) maternity unit to check compliance with a warning notice served in August 2011 and to follow up compliance actions from the last inspection report. We had issued a warning notice and compliance actions across FGH and Royal Lancaster Infirmary Hospital (RLI) maternity units. A separate report has been written for FGH. Although the previous report highlighted some different issues for each site there were common themes identified therefore it is beneficial to read this report in conjunction with the one for RLI.

The trust had made good progress in addressing our concerns contained in the warning notices and compliance actions from last year. It was evident that the trust was working with staff to develop a safe, women centred, evidence based maternity service. Good practice points were noted across both The Royal Lancaster and Furness General Hospital sites.

Clinical staff involved in the inspection gave us honest, helpful and well considered explanations. They were able to support their answers with robust examples and both written and verbal evidence. They demonstrated excellent skills in relationship building throughout the two days and were warm and welcoming.

Work is still ongoing, which is to be expected, around cultural change, staffing levels and data management systems but significant progress has been made to address these.

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During an inspection in response to concerns

We conducted an on site investigation into the emergency pathway at Furness General Hospital (FGH) on 20th February 2012 under the powers of section 48, Health and Social Care Act 2008. The remit of this investigation was to review the urgent care pathway. An investigation differs from a responsive compliance review in that it normally necessitates a much wider and deeper look at a range of concerns potentially across all locations within a single provider such as an NHS hospital. During the investigation the team identified a number of concerns that demonstrated a breech in the regulations.

The investigation team collected feedback from a wide number of people living in the local

area who had used the services provided by the trust. This will be reported in more detail in the investigation report which is due to be published in July.

People reported varying experiences when they received treatment and care at the hospital.

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During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

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During an inspection in response to concerns

We focused during our visits upon the experiences of the women using the maternity services across the Trust and on getting their opinions on the care and support they had received. We talked with mothers, their relatives, clinicians and midwifery practitioners and people expressed a range of largely positive views. Mothers we talked with confirmed that there were good levels of information provision across all three maternity units with mothers being given choice about the kind of care available to them.

The mothers we talked to told us that they understood their care and treatment and told us they were kept up to date about what was happening and given explanations about what was happening during their pregnancies and also during labour so they could make informed decisions. All the mothers we talked with expressed satisfaction with the care and support they had received from the midwives during their stay on the maternity units. All those mothers we talked to on the post natal wards told us the midwives had “always” asked them what they wanted during their labour and given them explanations. All those we talked to confirmed that once in established labour they had not been left on their own by midwives. We were also told that doctors and consultants spent time with them and explained why changes to their plan were needed.

One mother told us staff had been “brilliant” and had “acted quickly when things changed” and that “all the options were discussed with us”. Another commented on the fact that they had felt able to ask their consultant questions “all the way through being pregnant”.

Another mum who had been transferred between units told us “It was a very quick response, and they (staff) explained as much as they could”.

Mothers also commented that they could see staff were busy at times during their stays and one in Furness General Hospital told us “They were very busy when I came in, despite that they were always there for me”.

Inspection ratings

We rate most services according to how safe, effective, caring, responsive and well-led they are, using four levels:

Outstanding – the service is performing exceptionally well.

Good – the service is performing well and meeting our expectations.

Requires improvement – the service isn't performing as well as it should and we have told the service how it must improve.

Inadequate – the service is performing badly and we've taken enforcement action against the provider of the service.

No rating/under appeal/rating suspended – there are some services which we can’t rate, while some might be under appeal from the provider. Suspended ratings are being reviewed by us and will be published soon.

Ticks and crosses

We don't rate every type of service. For services we haven't rated we use ticks and crosses to show whether we've asked them to take further action or taken enforcement action against them.

There's no need for the service to take further action. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.

The service must make improvements.

At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.